Provider Demographics
NPI:1831854066
Name:GARCIA, GABRIELLA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:MARIE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-3535
Mailing Address - Country:US
Mailing Address - Phone:217-259-6799
Mailing Address - Fax:
Practice Address - Street 1:716 18TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2382
Practice Address - Country:US
Practice Address - Phone:217-345-7054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009354225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant